護理師照護一位裝有胸管並連接水封式引流系統的病人。下列哪項觀察結果需要護理師「立即」介入？
A nurse is caring for a client with a chest tube connected to a water-seal drainage system. Which observation requires immediate intervention by the nurse?
- AIntermittent bubbling in the water-seal chamber during coughing咳嗽時水封瓶內有間歇性氣泡
- B50 mL of serosanguineous fluid in the collection chamber over 2 hours2 小時內收集瓶中有 50 mL 漿液血性液體
- CContinuous bubbling in the water-seal chamber✓ 正解水封瓶內有持續性氣泡
- DFluctuation of the water level (tidaling) with respirations水位隨呼吸波動（潮汐現象）
胸管引流系統監測是風險降低的重要範疇。水封腔（Water-seal chamber）的設計是讓空氣只能從病人胸膜腔排出而不能回流。如果看到「持續性氣泡」（Continuous bubbling），通常代表系統有漏氣（Air leak），可能是引流管連接處鬆脫或是胸管移位，必須立即找出漏氣點。選項 A（咳嗽時有間歇性氣泡）是正常的，代表胸膜腔內的殘餘空氣正在排出。選項 D（水柱隨呼吸波動，Tidaling）也是正常現象，代表引流管通暢，若波動消失才要擔心管路阻塞或肺部已擴張完全。選項 B（2 小時引流 50 mL 漿液血性液體）在術後初期屬於可接受範圍（通常每小時超過 100 mL 才需立即回報）。
Continuous bubbling in the water-seal chamber indicates a persistent air leak in the drainage system or tubing, requiring immediate intervention to locate and fix the leak. Intermittent bubbling during coughing and tidaling are normal findings.
在美國護理標準中，護理師被要求具備獨立查漏的能力（從胸壁端向引流瓶端分段夾改以確認漏氣點）；台灣臨床則多由護理師先觀察並通知醫師，較少自行進行分段夾管測試。